The Sep 2015 OIG Report:  The Bad Apples
Written by Chris Dalrymple, DC   
Monday, October 12, 2015 06:26 AM

In September of 2015 the Office of the Inspector General (OIG) of the Department of Health and Human Services, a federal agency, released a report highlighting its evaluation of chiropractic claims and questionable and inappropriate payments for chiropractic services. This article looks at the findings of the OIG study reporting the “bad apples” of the chiropractic profession.

"In 2013, $76 million in Medicare payments for chiropractic services were questionable. … just 2 percent of chiropractors were responsible for half of the questionable payments.  These chiropractors provided more services to more beneficiaries compared to all other chiropractors and were located in high-fraud areas. … most of these chiropractors also had questionable payments in a prior year."

Just who are these 2% that are giving the rest of the profession a bad name?  The OIG report provides some insight. “In 2013, 962 of the 45,490 chiropractors paid by Medicare received $38 million of the $76 million in questionable payments.”  That is some $39,500 per chiropractor per year.  “These 962 chiropractors … received 9 percent ($43.6 million) of all Medicare payments for chiropractic services in 2013.”  That is over $45,300 per chiropractor per year.  Says the OIG “we identified 87 percent of their payments as questionable."

On average, this 962 “provided chiropractic services to twice the number of beneficiaries compared to all other chiropractors.  In addition, the chiropractors with high questionable payments had about 4 times of the number of paid chiropractic claims compared to all other chiropractors."

The OIG notes that where the average doctor of chiropractic was paid $10,303 per year by Medicare the average one of the 962 doctors received $45,313 per year.  Where the average DC had 407 paid claims per year, the average “bad apple” had 1,604 claims.  Where the average DC had 47 Medicare beneficiaries, the outliers had 101.

Tucked away in the OIG report is this statement “for the chiropractors with high questionable payments [the 962], 53 percent of their claims were suggestive of maintenance therapy.  In contrast, just 3 percent of the claims for all other chiropractors paid by Medicare in 2013 were suggestive of maintenance therapy.”  So while the OIG report seems to imply that some 50% of claims are “questionable” as potential maintenance therapy, the reality is that the 44,528 other DCs have only 3 percent of their claims considered as such.

For these 962 “bad apples” Medicare paid “substantially more for treatments to five regions of the spine, CPT code 98942.  Twenty-eight percent of paid services provided by [the 962] were for 98942.  In contrast, only 5 percent of paid services provided by all other chiropractors were for this CPT code.  Finally 30 percent of [the 962] received 95 percent or more of their Medicare payments for CPT code 98942, yet just 3 percent of all other chiropractors received 95 percent or more of their Medicare payments for this code."

The OIG tells us that “fifty-nine percent of [the 962] were concentrated in seven states:  California, Michigan, Illinois, New York, Kansas, Florida, and New Jersey.  Each of these states had more than 50 chiropractors with high questionable payments.”  The remaining 41 percent (471) were located in 38 other states.

These 962 DCs were likely to have also had paid claims for physical/occupational therapy on the same day.  The beneficiary for the “average” DC who had patients who also received therapy was reimbursed for therapy services $320 on average for 11 claims resulting in $930 being paid per therapist. The “bad apples” saw therapy services billed at $982 with 34 claims for an average payment per therapist of $4,680.  “The average payment to therapists for beneficiaries who received same-day services from [the 962] was five times higher than the average payment to therapists for other beneficiaries."

Not only were these 962 “bad apples” deemed to be such in 2013, but “almost half of [the 962] had at least one questionable payment in each year between 2009 and 2012, thus demonstrating that these chiropractors had a consistent pattern of questionable payments over a 5-year span."

It is 2% of the outliners are giving the rest of the profession a bad name.  


Source: http://oig.hhs.gov/oei/reports/oei-01-14-00200.pdf